Provider Demographics
NPI:1912022773
Name:GUPTA, PUNEET (PA)
Entity Type:Individual
Prefix:
First Name:PUNEET
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-0540
Mailing Address - Country:US
Mailing Address - Phone:319-768-3450
Mailing Address - Fax:319-768-3460
Practice Address - Street 1:1225 S GEAR AVE
Practice Address - Street 2:STE 254
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1691
Practice Address - Country:US
Practice Address - Phone:319-768-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001797363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
01149OtherWELLMARK BLUE CROSS BLUE
252993OtherMIDLANDS CHOICE
IAP00407816OtherRR MEDICARE
IAP00407816OtherRR MEDICARE